Background: Emergency surgery is a major component of the provision of surgical services and makes up a substantial volume of the workload of surgeons in many hospitals. It is often more complex and surgically challenging than elective surgery. However, little attention has been concentrated on the management or resource requirements of emergency surgery. Method: This article identifies principles for models of emergency surgery care and describes how they can be incorporated into a redesign of emergency surgery. They have been developed and are endorsed by experienced surgical staff routinely coping with the challenges of emergency surgery. Results: The benefits of redesigning emergency surgery will be realized by an active partnership between managers, surgeons and surgical teams. The anticipated clinical benefits include improved patient outcomes, enhanced patient and surgical team satisfaction, and increased trainee supervision in emergency surgery. Significant management benefits will ensue from high rates of emergency operating theatre utilization, reduced patient cancellations and reduction in after-hours costs. This unplanned but predictable workload will be managed in a planned and predictable fashion. Conclusion: Reform of emergency surgery services is a necessity and not a choice. The development of the emergency surgery guidelines for New South Wales is a step in the right direction. The principles identified in the guidelines should be adapted and implemented across Australia if sustainable, safe and efficient emergency surgery services are to be provided. Patients will expect nothing less.